Case Report
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World J Clin Cases. Oct 16, 2014; 2(10): 596-603
Published online Oct 16, 2014. doi: 10.12998/wjcc.v2.i10.596
Haemostatic management for aortic valve replacement in a patient with advanced liver disease
Laurence Weinberg, Irene Kearsey, Clarissa Tjoakarfa, George Matalanis, Sean Galvin, Scott Carson, Rinaldo Bellomo, Larry McNicol, Peter McCall
Laurence Weinberg, Irene Kearsey, Clarissa Tjoakarfa, Larry McNicol, Peter McCall, Department of Anaesthesia, Austin Hospital, Melbourne, Victoria 3084, Australia
George Matalanis, Sean Galvin, Scott Carson, Department of Cardiac Surgery, Austin Hospital, Melbourne, Victoria 3084, Australia
Rinaldo Bellomo, Department of Intensive Care, Austin Hospital, Melbourne, Victoria 3084, Australia
Author contributions: Weinberg L and McCall P were the principal anaesthetists who managed the case; both were responsible for the planning and writing of the case report; Kearsey I and Tjoakarfa C were responsible for all the data collection, collation of pictures and the writing of the case report; Matalanis G and Galvin S were the cardiac surgeons that performed the operation and were responsible for the writing of the case report; Carson S was the clinical perfusionist that managed the case and was responsible for the writing of the case report; McNicol L and Bellomo R were responsible for the co-management of the patient in the preoperative and postoperative period and were responsible for the writing of the manuscript.
Supported by Department of Anaesthesia Research Fund, Department of Anaesthesia, Austin Hospital, Melbourne, Victoria 3084, Australia
Correspondence to: Laurence Weinberg, MBBCH, BSc, MRCP, DipCritCareECho, FANZCA, Department of Anaesthesia, Austin Hospital, 145 Studley Rd, Melbourne, Victoria 3084, Australia. laurence.weinberg@austin.org.au
Telephone: +61-3-94965000 Fax: +61-3-94965000
Received: May 23, 2014
Revised: June 26, 2014
Accepted: July 25, 2014
Published online: October 16, 2014
Processing time: 145 Days and 2.9 Hours
Abstract

Redo-sternotomy and aortic valve replacement in patients with advanced liver disease is rare and associated with a prohibitive morbidity and mortality. Refractory coagulopathy is common and a consequence of intense activation of the coagulation system that can be triggered by contact of blood with the cardiopulmonary bypass circuitry, bypass-induced fibrinolysis, platelet activation and dysfunction, haemodilution, surgical trauma, hepatic decompensation and hypothermia. Management can be further complicated by right heart dysfunction, porto-pulmonary hypertension, poor myocardial protection, and hepato-renal syndrome. Complex interactions between coagulation/fibrinolysis and systemic inflammatory response syndrome reactions like “post-perfusion-syndrome” also compound haemostatic failure. Given the limited information available for the specific management and prevention of cardiopulmonary bypass-induced haemostatic failure, this report serves to guide the anaesthesia and medical management of future cases of a similar kind. We discuss our multimodal management of haemostatic failure using pharmacological strategies, thromboelastography, continuous cerebral and liver oximetry, and continuous cardiac output monitoring.

Keywords: Cardiac surgery; Liver failure; Coagulopathy; Cardiopulmonary bypass

Core tip: Cardiac surgery in patients with advanced liver disease is associated with significant morbidity and mortality. Refractory coagulopathy is common and requires a proactive multidisciplinary haemostatic management strategy. Given the limited information available for the specific management and prevention of cardiopulmonary bypass induced haemostatic failure, this report serves to guide the anaesthesia and medical management of future cases of a similar kind. We discuss our multimodal management of haemostatic failure using pharmacological strategies, thromboelastography, continuous cerebral and liver oximetry, and continuous cardiac output monitoring.